PA agency develops competency pathway

Project has been refined over past seven years

SNI Home Care of Langhorne, PA, has long been refining and expanding its competency pathway, which first became a quality improvement (QI) project in 1993.

"This fiscal year we have a competency program for all of the clinical staff, and now we’re developing one for the nonclinical staff and in-house people," says Beth Henn, RN, MS, director of quality management for the agency, which serves 11 counties in central Pennsylvania.

The agency’s work has resulted in a comprehensive competency program that incorporates the competency pathway with job functions and provides objective outcome scores that can be used by an employee to benchmark against other employees’ performances.

The competency program was presented successfully to an accreditation surveyor from the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL.

One of the important benefits of a competency program that provides objective scoring and benchmarking is that it results in concrete outcomes data that can be presented to managed care companies during contract negotiations. That was one of the reasons SNI developed the program, Henn says.

"Our chief executive officer said that we needed to show managed care companies that we really do have skilled nurses," she explains. "We can say we have wonderful nurses and all the patients love us, but everybody can say that."

Instead, the agency needed an objective tool to demonstrate evidence of the nurses providing quality care, she says. SNI’s competency pathway eliminates subjective evaluation criteria and measures four functions: credentials, documentation, daily performance, and observable job performance.

The program provides each employee with a "report card." Supervisors receive concrete feedback on employees’ performance and can use it to focus remediation efforts.

"Each area we score on is tied to an employee’s ability to get a raise or to move further up the organization," Henn says. "So each year, employees have control over how well they do, and they know if they don’t score at least 95% on the competency tests, then they don’t get a raise that year no matter how hard they work."

Here are some key features of the program:

Credentials: The human resource team tracks employees’ professional licensure, health requirements, and CPR certification. Professional staff who are missing any of those credentials are suspended from providing patient care.

Documentation skills: Documentation skills are measured through a peer review process. Employees who are not documenting charts or other paperwork correctly and consistently are subject to a focus review. If the chart audit indicates the employee does not understand proper documentation, then the supervisor will provide individual remediation.

Daily performance review: Each employee’s immediate supervisor completes the daily performance requirement section of the competency exam. For example, supervisors check to make sure employees return paperwork in a timely fashion and that they attend case conferencing and any required inservices.

Observable job performance: The agency’s goal is to have employees perform in the field as precisely and correctly as if they were being observed during a Joint Commission or state survey, Henn says. "They have one chance to do it, and they know we’re coming, and we’ll go through the whole visit with objective measures in safety and infectious control and responsibility."

For example, a supervisor may analyze a therapist’s or nurse’s hand-washing procedure. The supervisor observes how long the employee washes his or her hands and all of the steps the nurse takes in doing so. Each step of the process is scored.

The competency program also entails standardized testing in four areas. Those tests contain the same core competency materials that are used to evaluate staff during actual, on-site field assessments. "This allows us to make sure they are practicing what they preach," Henn says.

Staff must score 95% in each area. If they do not, they are placed in a remedial program. "So we hit the points each person does not understand," she says.

Staff can study at their own pace

Henn and two other quality improvement employees designed the competency program based on their research of the core competencies required for licensing and certification.

"We went back and looked at all the surveys from the Joint Commission to see if there were any deficiencies or recommendations to address," she says. "We read home care literature and looked at tips of areas the state and Joint Commission review."

Using that material, they began to write questions for the competency tests and developed material for a self-learning module. The competency tests are designed to take one hour to complete. Each includes 25 questions.

The self-learning modules were important to the program’s success because the field staff no longer have time to sit through lengthy inservices. This way, they can study at their own pace at times that do not interfere with client visits. "If we bring our field nurses into the office for inservices, we’re losing . . . business in the field," Henn explains.

Once the competency exams and self-learning modules were completed, the QI staff presented the material to a committee for review. The committee made some changes after several meetings, then the QI staff brought the revised tests to a small group on a trial basis. They made further changes, based on the pilot project.

The next step involved analysis of the results. Any areas that consistently gave staff difficulty became small performance improvement projects. The quality improvement team also fielded suggestions from the staff. When the refining process was done, the competency program was integrated more fully into the agency’s computer software.

Having a thorough and objective competency program enables an agency to be fully prepared for any surprise survey visits. "The staff will know all policies and procedures and do their tasks right 100% of the time," Henn says. "That’s the ultimate goal."

The staff at SNI may not be at 100% yet, but they have definitely improved and the program is working, she adds.

"I know it’s working because when I go out in the field and watch the staff do a procedure and they miss a step, they look at me and say, I know what I did wrong,’" Henn says. "In the past, they might not have known they missed a step, but now they do."

Beth Henn, RN, MS, Director of Quality Management, SNI Home Care Inc., 880 Town Center Drive, Langhorne, PA 19047. Telephone: (215) 641-8000.